Views

Medical mistakes

Five senior doctors write about learning from errors, and the rise of the patient safety movement

In 2005, the UK’s National Patient Safety Agency produced a booklet entitled Medical Error. It aimed to bring patient safety to the attention of junior doctors and to give advice on avoiding errors in patient care and dealing with them when they did occur. Perhaps the most eye catching and noted part of the booklet was a section entitled, My Mistake, in which, for the first time, senior and influential doctors talked openly about errors that they had made, each recounting a mistake and what they had learnt from it. As part of our themed issue on patient safety, we are here republishing four of those stories, with a new introduction for the Student BMJ by Liam Donaldson, World Health Organization envoy for patient safety and former chief medical officer for England, who explains why medical students should care about patient safety.

Patient safety matters

Understanding of, and commitment to, patient safety worldwide has grown since the late 1990s. This was prompted by two influential reports: To Err is Human,[1] in the United States and An Organisation with a Memory[2] in the United Kingdom. Both recognised that error is routine during the delivery of healthcare, affecting something like one in 10 of all hospital patients. In a proportion of cases the harm is serious, even fatal.

The reports also highlighted poor performance of healthcare, as a sector, worldwide on safety compared with other high risk industries. Notably, aviation has shown remarkable and sustained improvements in the risk to passengers of air travel over four decades. It has done so by recognising that most harm comes not from the actions of incompetent or negligent individuals but from weak systems that provoke error. A system is the way that the infrastructure, the processes of care, and the ways of working are organised, designed, delivered, and led. A patient who is killed because they are given the wrong drug intravenously will have died because an individual doctor or nurse made a mistake. These staff might have been working under pressure and the drugs might have been stored on a shelf with other drugs with similar labelling and packaging but different actions. Thus, it was too easy to make a mistake. Who is to blame for such a mistake: the doctor or nurse for not double checking before administering the drug or the system for creating unnecessary risks? This is at the heart of patient safety: the healthcare system needs careful, conscientious practitioners but it also needs to dramatically reduce the opportunities for error by going upstream to strengthen its systems.

Since the late 1990s, the quest to improve the safety of care for patients has become a global movement. Important bodies like the World Health Organization,[3] the Gulf Cooperation Council, the Agency for Healthcare Research and Quality,[4] and the European Commission have produced strategic documents, initiated programmes of action, and galvanised the support of political and health leaders worldwide.

Yet, the current state of patient safety worldwide is still a source of deep concern. As data on the scale and nature of errors and adverse events have been more widely gathered, it has become apparent that unsafe actions are a feature of virtually every aspect of healthcare. Reports of the deaths of patients regularly feature in media reports in many countries and undermine public confidence in the health services available to citizens. Moreover, many events like surgery on the wrong site or drug mix ups recur, with efforts to prevent them ineffective.

Previous generations of doctors have interpreted their role as solely treating patients. Many have had little interest in thinking about or assessing the safety and quality of their service and seeking to improve it. Had Peter Pronovost, an intensivist at Johns Hopkins Hospital restricted himself only to treating individual patients in his own intensive care unit, thousands of patients in Baltimore, other parts of the US and across the world would not be alive today. He redesigned the system of care and led a transformation that made major reductions in the level of fatal infections.[5] The changes were not just technical; they were cultural as well. They transformed the way that staff saw their role and how they worked together to make care safer—what is now referred to as “human factors.”

Thousands of patients would not be alive after operations across the world if Atul Gawande of Harvard University had not helped WHO to develop and implement the first surgical checklist.[6]

Medical students can play a major role in ensuring that this broadening in the philosophy of medical care is the paradigm of future practice. But even today, as they go on to the wards, they will encounter some reactionary forces that could discourage them. One of my mentees, inspired by the goal of making healthcare safer, took up a post in a district general hospital. Soon he was identifying adverse events and near misses and reporting them. Within a week he was accused of being a troublemaker and told to stop reporting.

Yet, the culture is changing. Many of the country’s senior doctors are playing key leadership roles in patient safety programmes. The NHS has the largest repository of reported incidents in the world at seven million. It is proving a rich source of learning so that we can stop history from repeating itself, as it has depressingly often in the past.

Meantime, even before qualifying, medical students can play an important role in spotting and surfacing risks in the care environment and occasionally challenging unsafe practice—“shouldn’t you clean your hands, sir, before examining that patient?” This takes courage but a culture that discourages such healthy challenge is a dangerous place for patients. The movement to create safer care now has unstoppable global momentum, and today’s medical students will be at its centre as the doctors of the future.

Simon Eccles, medical director, Department of Health Informatics Directorate and clinical lead for emergency medicine, Homerton University Hospital, London

Within two weeks of my first registrar post, I’d made an error that nearly cost my patient her life.

I was a registrar in accident and emergency. A woman presented with a severe headache that had woken her up. She was anxious and had tremendous tenderness in her scalp. I focused on the anxiety and scalp tenderness and diagnosed a tension headache.

I sent her home and told her to come back if she didn’t get better. Four hours later, she returned to accident and emergency. She was seen by a colleague who sent her for a computed tomography scan and diagnosed a subarachnoid haemorrhage. I’d ignored the most important symptom—the sudden waking from sleep—and failed to realise that she had a very serious condition.

The patient complained. I was devastated. I was a new registrar trying to polish my spurs, and I’d made a schoolboy error in my first two weeks. My consultant was supportive and helped me learn where I’d gone wrong. My biggest lesson was that as a registrar you don’t know as much as you think you do.

I’m about to become an accident and emergency consultant. The maxim “there are no awards for bravery in medicine” rings true for me. A lot of queries from senior house officers involve asking for permission to be brave. My advice is to ask yourself whether you’ve ruled out something serious that could harm the patient. I also tell senior house officers that if you haven’t written it down, it hasn’t happened. I’m not advocating defensive medicine, but cautious medicine.

An open culture would do medicine the power of good. We might have several years of headlines about how unsafe healthcare is, but in the long term it will improve trust between doctors and patients.

Richard Horton, editor, Lancet

My mistake involved a man in his early 40s with chest discomfort. He didn’t speak much English and no translator was available. He was on steroid replacement therapy for Addison’s disease.

Judging from a mix of gestures and half formed sentences, the discomfort didn’t seem to be the crushing pain of cardiac ischaemia. He seemed to agree when I asked if the pain was worse when he lay down. Physical examination showed nothing relevant, although I persuaded myself of epigastric tenderness. The antique electrocardiographic machine worked erratically, but the trace looked normal.

All coronary care beds were occupied. Moving a patient to the ward to make way for a man with probable gastro-oesophageal reflux would have attracted derision from the cardiologists in the morning. I put the patient on a medical ward instead. Thinking of his hypoadrenal state, I considered additional hydrocortisone but decided I was over-reacting. The man had heartburn, I thought. He probably didn’t even need to be in hospital.

At 5.30 am a nurse found him dead. I was stunned. I was sure he’d died of a fatal arrhythmia secondary to an infarct that I had missed, or from an Addisonian crisis that I could have prevented. When I presented the case on the ward round, no difficult questions were asked. A necropsy would have revealed all, and I was prepared for some serious interrogation. But the family refused a necropsy on religious grounds.

My experience raises questions not only about my judgment, but also about the need for senior cover for younger colleagues, the availability of coronary care beds, the provision of translators, and the value of necropsy. We need to talk and write honestly about mistakes and discuss the lessons that can be drawn from them.

Elisabeth Paice, chair of the North West London Integrated Care Pilots, former dean director, London Deanery

I was a new consultant rheumatologist. I admitted a woman whom I diagnosed as having dermatomyositis. I organised a cancer screen, including a chest x ray, because of the association with malignancy. The hospital was full, so the patient was moved to another ward before my round. When I saw her, the x ray was not available, having disappeared between the previous ward and the current one. All the other tests were as expected and she was discharged.

Two weeks later I saw her in an outpatient clinic. She was responding well to treatment. I repeated her blood tests but forgot that I had not checked the x ray.

It was months before I noticed that the x ray report was not in the notes and opened the envelope to look at the film. The film showed an obvious tumour, duly identified by the radiologist whose report was still in the envelope. I had to tell the woman that she had cancer, that I would have to refer her to a cancer specialist, and that the delay in doing so was my fault. She died not long after because of an allergic reaction to her first dose of chemotherapy.

There is no doubt that it was my responsibility to check the result of a test I had ordered, and there was no excuse for failing to do so. However, there were other factors that helped set up the situation. The patient was moved from one ward to another and the x rays did not go with her. There was nothing in the discharge report to prompt me to follow up the x ray. The x ray department normally phone about abnormal results, but I didn’t get a call. Ultimately, though, I was culpable.

I cared passionately about this patient but found that I’m perfectly capable of forgetting things. This made me put lots more checks in place so that I don’t rely on memory alone. We also changed the system for dealing with x ray reports. A copy is detached in the x ray department and sent separately to the doctor for checking.

What I learnt was that if I requested an investigation, I had to take responsibility for remembering to check the result.

Parveen Kumar, professor of medicine and education at Barts and the London School of Medicine and Dentistry; hon consultant physician and gastroenterologist at Barts and the London and Homerton University Hospitals Trusts and co-editor of Kumar and Clark’s Clinical Medicine

When I was a houseman, I made a mistake that really shook me up. I was looking after a 19 year old man with acute myelogenous leukaemia. He was being treated with a new cytotoxic chemotherapy drug called rubidomycin. Late one evening, I was mixing and drawing up the drug into several syringes. I felt sure that I’d worked out the correct doses, but as this was a trial drug I thought I had better double check.

I asked the ward sister to check the syringes before I gave the man his treatment. To my horror, the nurse found that I’d drawn up 10 times the right concentration. With the nurse’s help, I then prepared the right dose and treated the man correctly.

It was hard to admit the mistake, but I did tell my registrar and he appreciated my honesty. I was much more careful about prescribing drugs after this, and have since taken great care to look up dosages in the BNF.

This near miss has stayed with me. It made me realise the importance of asking for help. Some doctors don’t like to do this. They worry that their colleagues will think they are no good. But making mistakes because you haven’t consulted your colleagues will be far more harmful to your reputation. More importantly, it will be harmful to your patients. If I hadn’t asked the nurse to check the drug doses, there’s a very good chance that the man would have died.